Cardiology

Dr ISAAK M OSMAN
MBchB, Mmed
Int. Medicine/Cardiology
10th Sept 2019
 Course Outline
 Functional anatomy and
physiology
 Investigations for CVDs:ECG
 Presenting problems in
cardiovascular disease
 Heart failure
 Cardiac arrhythmias
 Coronary artery disease
 Peripheral arterial disease
 Diseases of the aorta
 Hypertension
 Diseases of the heart valves
 Infective endocarditis
 Congenital heart disease
 Diseases of the myocardium
 Diseases of the pericardium
Functional anatomy and physiology

• The heart acts as two serial pumps:

• The right heart -circulates blood to the lungs.
• The left heart -circulates it to the rest of the body.
• The atria are thin-walled structures.
• Situated posteriorly within the mediastinum
• Left atrium (LA) sits anterior to the oesophagus and descending aorta.
• Right atrium (RA) receives blood from the superior and inferior VC & the coronary sinus.
• The LA receives blood from four pulmonary veins.
• The atria and ventricles are separated by the annulus fibrosus;
• forms the skeleton for the atrioventricular (AV) valves and electrically insulates the atria
from the ventricles.
• Normally, the heart occupies less than 50% of the transthoracic diameter in the
frontal plane.
Direction of blood flow through the heart and Normal Pressures Surface anatomy of the heart
Coronary circulation
• The left main and right coronary arteries arise from the left and right
sinuses of the aortic root-distal to the aortic valve.

• The left main coronary artery divides into:

• Left anterior descending artery (LAD), which runs in the anterior interventricular
groove.
• Left circumflex artery (CX), which runs posteriorly in the atrioventricular groove.

• The LAD -supply the anterior part of the septum (septal perforators) and
the anterior, lateral and apical walls of the LV.
Coronary circulation cont..

• The CX -supply the lateral, posterior and inferior segments of the LV.

• The right coronary artery (RCA) runs in the right atrioventricular groove
• supply the RA, RV and infero-posterior aspects of the LV.
• The posterior descending artery supplies the inferior part of the
interventricular septum.
• This vessel is a branch of the RCA in approximately 90% of people
(dominant right system) and is supplied by the CX in the remainder
(dominant left system).
• The RCA supplies the sinoatrial (SA) node in about 60% of individuals and the AV
node in about 90%.
• The venous system follows the coronary arteries but drains into the coronary sinus
in the atrioventricular groove- and then to the RA.
Conduction system

• SA node:
• Situated at the junction of the SVC & RA.
• Comprises specialised atrial cells that depolarise spontaneously.
• During normal (sinus) rhythm, this depolarisation wave propagates through both
atria.
• The annulus fibrosus forms a conduction barrier between atria and
ventricles-the only pathway through it is the AV node.
• AV node- midline structure, extending from the right side of the interatrial
septum, penetrating the annulus fibrosus anteriorly.
• AV node conducts slowly- giving a necessary time delay b/w atrial and ventricular
contraction.
Conduction system cont..

• The His–Purkinje system- composed of:

• The bundle of His -extending from the AV node into the interventricular
septum
• The right and left bundle branches -passing along the ventricular septum and
into the respective ventricles
• The anterior and posterior fascicles of the left bundle branch
• The smaller Purkinje fibers that ramify through the ventricular myocardium.
• The tissues of the His–Purkinje system conduct very rapidly and allow near-
simultaneous depolarisation of the entire ventricular myocardium.
The cardiac conduction system
Nerve supply of the heart
• Innervated by both sympathetic and parasympathetic fibres.

• Sympathetic nerves from the cervical sympathetic chain supply muscle

fibres in the atria and ventricles, and conducting system.

• Activation of β1-adrenoceptors positive inotropic & chronotropic effects

• Parasympathetic fibres reach the heart through the vagus nerves.

• Supply AV and SA nodes via muscarinic (M2) receptors.
 Nerve supply of the heart

• Under resting conditions, vagal inhibitory activity predominates and the

heart rate is slow.

• Adrenergic stimulation -associated with exercise, emotional stress, fever -

causes the heart rate to increase.

• In disease states, the nerve supply to the heart may be affected.

• In heart failure the sympathetic system may be up-regulated

• In diabetes mellitus the nerves themselves may be damaged by autonomic

neuropathy -so that there is little variation in heart rate
Cardiac peptides
Cardiomyocytes secrete peptides that have humoral effects on the
vasculature and kidneys.
• Atrial natriuretic peptide (ANP)
• Acts as a vasodilator -thereby reducing blood pressure (BP)
• Acts as a diuretic -promoting renal excretion of water and sodium
• Released by atrial myocytes in response to stretch
• Brain natriuretic peptide (BNP)
• produced by ventricles in response to stretch
• Like ANP, it has diuretic properties.
• Neprilysin
• An enzyme produced by the kidney and other tissues.
• Breaks down ANP, BNP- in doing so, it acts as a vasoconstrictor
• Forms a therapeutic target in patients with heart failure.
Respiration
• Cardiac output, BP and pulse rate change with respiration as the result of changes in blood
flow to the right and left heart.

• During inspiration the fall in intrathoracic pressure causes increased return of venous
blood into the chest and right side of the heart, which increases cardiac output from the
RV.

• A substantial amount of blood is sequestered in the lungs- this is due to increased

capacitance of the pulmonary vascular bed and causes a reduction in blood flow to the left
side of the heart.
• This causes a reduction in cardiac output from the LV and a slight fall in BP in inspiration.

• With expiration the opposite sequence of events occurs; there is a fall in venous return to
the right heart with a reduction in RV output, and a rise in the venous return to the left
side of the heart with an increase in LV output.
Respiration
• BP normally falls during inspiration but rises during expiration.
• These changes are exaggerated in patients with asthma or COPD leading to
pulsus paradoxus, which describes an exaggerated fall in BP during
inspiration.
• Pulsus paradoxus is also found in cardiac tamponade. Here, cardiac filling is
constrained by external pressure, and on inspiration compression of the RV
impedes the normal increase in flow through it on inspiration.

• The interventricular septum then moves to the left, impeding left ventricular
filling and cardiac output.
• This produces a marked fall in BP (> 10 mmHg fall during inspiration).
• END